The terms “attention disorder” and “hyperactivity” are applicable not only to certain children but also to the social context of Western industrialized societies. Individual behavior problems are coupled with individual gifts and creative potentials—a fact which must not be overlooked in diagnosis or treatment. The article provides a differentiated discussion of the therapeutic options offered by anthroposophical medicine and homeopathy in general and of their remedies in particular. These offer an effective curatively-oriented alternative to the use of stimulants (e.g. Ritalin), which are of dubious clinical value as they are purely symptomatic.

We make a thorough, highly detailed biographical anamnesis and family anamnesis and from the start we place particular emphasis on describing not just the weaknesses, but also—in fact, primarily—the strengths of the child. - H. Köhler (1)

What is an attention disorder? The English term "Attention Deficit Hyperactivity Disorder" (ADHD) has supplanted the term "hyperkinetic disorder" (2, 3).1 Its leading symptoms are:

The nature of the disorder from which these children suffer is expressed more clearly by the English language than it is in German: "These symptoms"—see above—"are pervasive and interfere with the individual’s ability to function under normal circumstances" (4). "Pervasive" indicates a behavioral disorder that is “dominant” and manifests in different situations. “Normal circumstances” refers to “settings” typical of societies with a “Western life style”_family (nuclear), kindergarden and school. What it means to “function” in circumstances that adults would consider “normal” today is clearly expressed by child psychiatrists Schmidt, Meusers and Momsen in their work on ADHD: “The hyperkinetic disorder is primarily a disorder of impulse control. Before carrying out an action, we all normally consider if it sensible, appropriate or right, while these patients”_they are referring to children_”have the problem that the will shoots through before reflection and leads to an action that may later be regretted or lead to an unpleasant result” (5).

What is presented here as the “normal” relationship of thinking to acting reflects exactly the reigning paradigm of thought and behavior in technologically advanced Western societies. However it fails to take into account the evolution of a child’s consciousness and action. It also fails to acknowledge the existence of an artistic, creative type of thinking characterized by an intense openness to everything that is new and arises in the moment. As artists or inventors, human beings can free themselves from the calculated certainty of rationally determined action (theirs could rightly be called a “risk-taking” style of thinking and behavior).

It must be pointed out, however, that the leisure-time and parenting behavior of adults tends not to fit the criteria posited above. One need only think of adult behavior in regard to food, alcohol and tobacco. What is more, it has been proven that parents’ consumption of alcohol and nicotine during pregnancy promotes the very symptoms which medicine then diagnoses as ADHD in their children. There is much evidence that “partner conflict, psychological disturbance in the parents, parenting deficits and disorders in the parent-child relationship” (6) strongly influence and may impair children’s attention, impulse control and movement behavior. The behavior modeled here seldom bears much relation to the paradigm of planned or considered action!

In fact it is technology_learning to drive safely, having an occupation in a technologically based modern society_that educates the adult towards a behavioral style with:

• focused attention (shutting out the surroundings as a whole in favor of exact, primarily visual attention to selected events)• planful action directed towards a future result• relinquishing one’s own physical activity, suppression of one’s own movement needs in favor of intellectual control by way of by machines

The same is true of the economic necessities connected with technology. Moreover, the style set by them penetrates into the upbringing and education of our children, into our approach to dealing with patients and thus also into the way hyperactive children are dealt with: Medical, pedagogical and social norms take on the value of technical norms and are implemented as a form of “management” or “self-management.” The ability “to function under normal circumstances” is thus an historically relative criterion. In this connection Schmidt, Meusers and Momsen cite a remarkable prognosis made by Rudolf Steiner in 1920, the year of the inauguration of anthroposophical medicine: “... The human being is not just an intellect, after all; he has something else in his being: He has sensations, he has feelings, and these have to come to terms with what comes from the technological devices, from machines. And another feeling arises than what I spoke of before. I spoke of a feeling of longing arising out of deepest deprivation. What is gathered by the soul in the unconscious from its encounter with technology ... rises up as a reaction; it enters consciousness in the form of thoughts and ideas, but it comes up as something similar to fear. And in their longing out of deepest deprivation, the children we will have in school in the coming years and decades will begin to manifest an indefinite but very real fear of life, which will express itself in anxiety. It will express itself in fidgetiness, in nervousness—I mean this tangibly” (7).

This makes clear that the change in consciousness evoked by technology can also be experienced on the soul level as alienation from life, as imprisonment in an outwardly imposed set of circumstances, as loss of the experience of one's own presence and capacity for spontaneity. The question is, can the parents, teachers and doctors of these children recognize and consider this aspect, which is the “flip side” of the disturbing ADHD symptoms: the fear of losing one’s creative potential. In fact, under different circumstances the style of perception, impulsivity and driven motor activity that is labeled as ADHD today could even represent advantageous behavior (typical of the “hunter” of pre-industrial societies) (7), and many creative personalities _in Western societies too_display traits of ADHD.

Urge to assume Longing for trustworthyleadership over peers authority; and adults genuine leadership qualities in some cases

A personality that exemplifies these paired qualities well is that of Winston Churchill. Son of a “suspected-ADHD” father who devoted almost no time or attention to his son, as a schoolboy Churchill showed every sign of an attention disorder. He made progress only when motivated by a personal interest. Throughout his life what gave him most energy were military confrontations. In 1940, after an already turbulent political career he led Great Britain through what seemed an irrational and hopeless confrontation with Germany, letting not even national bankruptcy stop him (which all previous “normally functioning” British politicians wished to avoid). Churchill, who had the longest and most successful political career in the history of Great Britain, was awarded the Nobel prize in literature for his powerful literary achievements and was also quite active artistically as a painter.

Another example is the successful inventor Thomas Alva Edison, who received more than 1,000 patents and was always working on several inventions at once. He saw sleep as a waste of time and permanently revolutionized the life and sleeping habits of his contemporaries and future generations with his invention of the light bulb. A total failure at school, at the age twelve he left home and got by for a time working odd jobs. How would he be diagnosed and treated in our times? Who would recognize and promote the talent in this “difficult boy”?

In literature, Astrid Lindgren created a figure_Michel of Lönneberga_who casts light on many facets of ADHD: his trying qualities, the suffering as well as the deep understanding of his parents, the lack of understanding of his fellow townsmen who want to buy him a one-way ticket to America (his mother throws all the money they collected out the window), and finally his path to becoming chairman of the town council…

In view of these facts, we must object to the definition set down by well-known ADHD expert C. Neuhaus: “The moment abnormal behavior ceases to have positive repercussions and becomes a source of constant trouble for the individual, it is not creativity but a disorder” (10). Since the days of the Pharisees we have been aware that getting into “constant trouble” is not just the fault of those who allegedly cause it, but equally that of those in positions of societal responsibility who react negatively to abnormal behavior, seeing the mote in the other’s eye but not the beam in their own. Hence in composing the definition of ADHD, the authority who defines what is normal must also be scrutinized. The reason this dimension goes unmentioned in much of the scientific medical literature is that medical training today is dominated by the scientific paradigm. Yet there is no “normal value” that conclusively separates ADHD as a disorder or disease from the all the possible healthy paths of development in children. The diagnosis, rather, is based preponderantly on an act of understanding of child behavior. This is underscored by the fact that there is no scientific test for a diagnosis of ADHD. The German pediatric guidelines make this perfectly clear: "The diagnosis is to be derived from the patient’s life story" (11). Even questionnaires have a very relative value; and over extensive psychological testing, the guidelines give priority to making "a rough evaluation of the child's intellectual capacity and attentional behavior in school based on teacher's evaluations and grades. Examination of school bag and notebooks (orderliness, completeness, handwriting, organization) will provide an indication of disorders of visuomotor coordination (writing), attention (careless errors) and weakness in reading and spelling." It becomes clear that what is being measured by these criteria is the child's adaptation to conditions in the modern nuclear family, the modern kindergarten (25 children, noise level around 85 dB) and the achievement expectations of modern education; to apply the term "disorder" here is to move quite far from the concept of pathology as applied to a case of meningitis, oligophrenia or even a psychotic illness.

It is noteworthy that the diagnosis of ADHD is preponderantly applied to boys. The ratio of boys to girls varies between 3 : 1 and 9 : 1 (4, 12, 13)! For ADD without hyperactivity a ratio of 2 : 1 is assumed, although without hyperactivity "the validity of the ADD type is problematic" (Steinhausen), i.e. the dividing line from "normal" can "no longer be validly distinguished." On the other hand, ADHD is considered to be genetically based to a high degree (a number of recent studies put the inheritance rate at approx. 80 %)—yet the twin studies on which these results are based show no "boy-preference" (cf. 14)! The genetic aspect is assumed to act pathogenetically chiefly through a disturbance in dopamine metabolism (as yet unproven) as well as other possible neurotransmitter disorders in the brain, thus causing the abnormalities in these children. This thesis is equally incapable of explaining the sex difference in rate of affection.

Thus regarding the asymmetrical distribution of ADDH between boys and girls there is an obvious contradiction between the scientifically measurable aspects (genetics and neurobiology) on the one hand and phenomenological observation (pedagogical and clinical) on the other. Historically, the development of technology, the industrialization of the workplace and the associated social changes have been enormously significant. On an historical and social background, some of the crucial traits of the growing-up experience in societies with a Western lifestyle today are that:

• modern media have dramatically affected family life, sharply reducing children’s mobility, the alternation of speaking and listening, collective play and family rituals (e.g. meals).• the great majority of girls and boys are brought up by women (mothers, kindergarden teachers and most elementary school teachers).• children generally experience their fathers only during leisure time or—if parents are separated—every other weekend at visiting time, or not at all.• it is increasingly rare for children to experience their own movement as a meaningful necessity due to the mechanization of household and transportation.• significantly, boys seldom experience “typically male” movement patterns—e.g. activities requiring physical strength and endurance—and when they do these are usually optional athletic activities, not ordered work with social significance and value.• places of freedom (e.g. settings in nature) where children can experience their own movement, impulses and alternating attention, are increasingly disappearing.

An appeal is made here to the pediatric world, inasmuch as it is dedicated to serving the individual: Explain to all those in a position of responsibility—parents, teachers, politicians and those active in disease prevention—how the framework of children’s lives can be transformed so that problems such as ADHD lose their present pervasiveness and urgency.

In this connection, Henning Köhler’s book War Michel aus Lönneberga? (Was Michael from Lönneberga?) (9) offers a great many concrete and practical suggestions that not only help to successfully “manage” ADD as an adaptive strategy (cf. 15, 16), but also take seriously the special capacities and strengths of the affected children and turn them in a productive direction.

1 Diagnostic Aspects1.1 AnamnesisAll authors are in agreement that a thorough and undisturbed anamnesis conversation with the parents—always both parents if possible—is of the highest importance for diagnostic purposes. Practically speaking, one may proceed as follows:

• Ask the parents to send an informal letter to their doctor explaining everything they know of the history of the illness and their own observations of the child and providing a description of the family’s life circumstances, a list of the child’s other illnesses and treatments received, as well as the observations of others (relatives, kindergarden and elementary school teachers).

The advantage of this procedure is that it eliminates the time pressure: Forgotten points can be added later. The parents can concentrate on gathering and discussing their memories and can express themselves freely without being constrained by the presence of the child. They can also give voice to the burdens they have borne. In this way the parents come to the anamnesis conversation prepared—and so does the doctor, who has read the letter beforehand. If the letter is handwritten, the doctor gains additional important impressions of one of the parents. At the same time a significant part of the anamnesis will already be documented, thus taking more pressure off of the conversation. A further recommendation is:• Keep the anamnesis conversation separate from the presentation of the child.

In any case, whether physician is a pediatrician or a general practitioner, it is essential to allow for sufficient time: as a rule presently, one hour for the initial conversation in cases of suspected ADHD, regardless of what the fee schedule may permit (questionable norms come into question as soon as ADHD is involved!). This is the only way to provide the space needed for creative diagnosis and treatment selection.

Regardless of the patient's present age, it is crucial to begin by inquiring into the first seven years of life. Leading symptoms of a disorder requiring treatment may be:

Early childhood• temporal dissociation between language acquisition, motor development and other learning (e.g. toilet training), marked prematurity/retardation of specific “behavior competencies,” e.g. fine motor skills, language comprehension skills, etc.• driven, restless motor activity, low endurance (usually with some significant exception!), unpredictable and frequent changes in activities, enjoys risky behaviors, increased accident-proneness • “socially difficult” due to bursts of impulsiveness, disinterest in listening (often not true when they are told stories alone), frequent rule-breaking behavior, early and inappropriate need to lead, highly defiant assertion of autonomy. Because of this, child and family may find themselves socially isolated and siblings may be made into enemies or victims. Disturbance in the ties of family and friendship (with this particular symptom, the reverse process may be operative— attentional and behavioral disorders may result from separation of parents or loss of a loved one, etc.)• situational aggravation of the problems, especially in kindergarden. Kindergarden in its present form is usually a particularly unfavorable setting for hyperactive and attentionally disturbed children. The picture is different in kindergardens with small groups that can move freely in natural settings, such as the “forest kindergardens.”2• This is also the place to inquire into any allergic illnesses and reactions, get a detailed history of eating habits and digestion (dysbiosis/fungal illnesses?) and ask whether they have observed any aggravation of behavioral abnormalities connected with specific foods or improvements during an elimination diet.

As we have pointed out above, these behaviors are generally paired with special capacities and “behavioral plusses.” Thus, an early talent may be noticed for acrobatics (many affected children love the circus and circus games), or a climbing ability, a creative gift, etc.

As a rule, given a careful anamnesis and observation of the 5-year-old child at the 9th preventive care examination, it will be possible to recognize an attentional disorder with hyperactivity and to treat it satisfactorily without the use of stimulants. The symptoms linked with ADHD in school-age children are well-known: • easily distracted, forgetful, lack of care and perseverance (particularly at unappealing homework and household chores), disruptive, impulsive, defiant social behavior,• strikingly bad handwriting, trouble with reading/spelling, continual speaking, rushed speech,• affective lability and low self-esteem, outsider position in contrast to mental gifts.

Once again there is another side: Extremely hyperactive boys are also able to fish quietly with their father for hours, and in frightening or emergency situations (e.g. a fire) these children do the right thing with amazing sureness and presence of mind and later show excellent recall of even the smallest details.

Further features of the picture in adolescence: • leaving school prematurely/repeatedly• social isolation, continual conflicts with others, few or no friends• attraction to dangerous sports, risky behavior in driving, etc.• continual need for distraction, inner unrest

Issues relating to drugs, addictive dependency on media and computer games and socially problematic experiences with peers are of growing significance.

Much public attention is now drawn to the danger of leaving ADHD untreated in young people and adults. At issue, however, are not only those affected but equally the society in which they live. At bottom, the only way to make a difference in the increasing marginalization of these individuals is though a genuine understanding of their difficulties and specific gifts—not by a suppressive approach (e.g. use of stimulants)

The controllability of stimulant therapy is also generally unreliable; and for this reason as well, the therapeutic goal in adolescence must be to provide those affected with the support, treatment and appropriate social integration they need to become and remain free from daily tablet taking at this stage in their life.

Making a Family AnamnesisThe most important aspects to ask about are:• The course of the pregnancy and birth. A quick or difficult birth, intubation at birth, etc., may have caused lasting disturbances of the craniocervical transition and can be effectively remedied with appropriate therapy (see below). In addition, we (the authors) have also observed what American classical homeopathists and ADHD experts Ullmann and Reichenberg-Ullmann report, namely that "the thoughts and feelings experienced by the parents just before conception and during pregnancy can have a direct effect on the condition of the child" (20). In their book Ritalin-Free Kids, these authors offer impressive casuistic proof— recognized by ADHD specialists—of the efficacy of homeopathically potentized remedies in these areas (21).• Exposure to toxic substances (chiefly pharmaceuticals, nicotine, alcohol and other drugs). The importance of these factors is generally recognized today (6). Therapeutic remediation is possible to an extent—chiefly in the first seven years of life—using approaches requiring practice and habit change and to an certain degree employing homeopathic and anthroposophic remedies.• Constitution of parents and grandparents: During the ADHD discussion and diagnosis process many parents become aware for the first time that they themselves display certain traits (or did so as children) which now confront them in their children. This realization can often lead to:• a new understanding of how their child actually feels • a certain calming of the situation, since in the course their lives many parents have ultimately made something positive of their difficulties and would not really want to be "completely normal"• a therapeutic opportunity, inasmuch as progress brought about by learning and behavior change in the parents is often the most productive.

Frequently when parents recognize that they have a particular style of attention and impulsivity themselves, they develop a new understanding for one another—and this in itself is a good reason why the parents of a child with "differences" should be thoughtfully integrated into the treatment. Parents learn that by being more attentive to their own impulsiveness and mastering it—in some cases giving up drugs, etc.—they are helping their children by sparing them the kind of disappointments and unhealthy experiences they have had. This also enables them to work through even severe disappointments or difficult separations of their own.

Finally, also important are reports from kindergarten and school, etc., as well as taking up direct contact with teachers. During treatment a regular common meeting time can be arranged with the parents and class teacher. School notebooks and any pictures, etc., done by the child should of course be personally perused by the physician.

1.2. Examination and Differential DiagnosisThe preliminary written anamnesis (parent's letter) and parent conversation free up the examination visit so that it can take place in a relaxed atmosphere. The doctor's aim must always be to experience the child directly: in a one-on-one conversation, a play situation or at least a wordless dialogue in gestures followed by an appropriately designed physical examination. In this way constitutional traits often become evident from the first impression of the child's appearance and answering behavior. An essential question is the child's capacity for dialogue: How does (s)he respond to eye contact and how long will (s)he tolerate it? What does (s)he notice in the examination room; how does (s)he relate to people and things; how quickly does his/her attention switch? – Does listening closely to the child permit a successful dialogue? At pre-school age, the chief focus will be on behavioral evaluation in regard to attention, impulsivity and motor behavior (here again one can use play to draw the child "out of his shell"). Surprisingly often, school-age children with ADHD issues are capable of voicing a deeply insightful self-evaluation of their situation when a free, unstressed conversation situation has been created (with parents absent or truly restraining themselves). In many instances issues that were long hidden come out, to the surprise of all involved, or interests are recognized that lead to important progress. The primary points to clarify in the anamnesis and examination are: • Is there a hyperactive disorder requiring treatment according to the criteria defining ADHD?• Are there grounds to suspect an attention deficit disorder (ADD) without hyperactive behavior?

For differential diagnosis, the primary focus is on reactive behavioral disorders caused by stress to the child from:• family (problems in parents' relationship to child and in parenting, unrealistic expectations, parental relationship problems, occupational/economic stresses, problems with siblings and close relatives; "family secrets" that were never aired• kindergarden or school (excessive demands for achievement, teacher with difficult personality, etc.)• depressive disorders must also be identified. Among boys these may well be coupled with hyperactive behavior and in most cases impair attention (sometimes severely). Also significant in this connection are:• peripheral and central hearing disorders (these must always be eliminated.)• autistic disorders; in rare cases, psychoses• endocrine disorders (chiefly of the thyroid gland and adrenals)

Vegetative lability and hypotonic circulatory condition can be read from skin color, distribution of body warmth, perspiration and posture; particularly in the 2nd seven-year-period it is important to perform blood pressure checks (also when standing) and measure blood sugar level (a.m., 2 – 3 hrs. after leaving home). Disorders in the interaction of upper and lower jaw, asymmetries in the cervical spine, alternation of tensed and hypotonic areas in dorsal musculature and postural anomalies may point towards

• disorders of the craniocervical transition area

as a source of trouble. Preventive care visits (particularly the 7th – 9th) are valuable diagnostically, offering the opportunity to observe the child's movement patterns and manner of speaking and answering while playing together (at ball or movement games such as pullstring puppets, etc.) and having the child balance, draw pictures or figure eights, write (writing position) and manipulate objects in the examining room (fine motor skills). These observations, in conjunction with the developmental anamnesis and possible later tests, —can provide diagnostic indication of

• competency deficits

An essential component—for differential diagnosis as well—is an evaluation of the child's intelligence and gifts, including a judgment as to whether the demands placed on the child are commensurate (under-/over-demand). The use of labels such as "highly gifted" may not always be productive here, since in reality these children largely suffer from great discrepancies—e.g. between their aptitude for mathematical/logical thinking and for social learning ("emotional intelligence"), or between their artistic gifts and their reading/spelling ability.

The level of differential diagnostic certainty needed must be decided on individually—i.e., to what degree one should implement complementary psychiatric testing, pedaudiologic examination, allergological diagnosis including evaluation of intestinal flora, endocrinological diagnosis and an EEG. In any case, however, the following aims should be borne in mind:• Before diagnosis: The pediatrician or family doctor should develop a well-rounded picture of the child and out of it a preliminary diagnosis;• After the diagnostic process described: The results and conclusions should be thoroughly discussed in a group conversation leading to common agreement on the therapeutic avenue to be taken. As a participant in the group, the child should feel helped and supported: As Köhler puts it, "the personal relationship is the actual therapy." A conversation among all adults concerned has proven of the greatest value. Primarily, this should include the parents, kindergarden or class teacher, therapists/curative educators and the responsible physician (cf. the principle of the "protective circle," Köhler (22)). Through this type of conversation a comprehensive view of the child, including both weaknesses and gifts, can arise. Diagnoses, goals and responsibilities can be discussed and clarified.

2 TherapyIn the authors' practice, the following ADHD-associated disorders have been found to be of diagnostic and therapeutic significance:• Disorders involving a constitutional dominance of the metabolic-limb system which manifests as a hyperkinetic disorder (ADHD)• Attentional disorders without hyperactivity (ADD). With this second form particular, competency deficits (including acquired ones) have proven to be of considerable pathogenetic importance.• Disorders in the area of the craniocervical transition.• Vegetative lability, labile hypotonic circulation.• Food intolerances; nutritional, digestive and metabolic disorders.

Therapeutically, a great deal depends on classifying the child's disorder correctly within this schema, so that one can implement a treatment that has a clear aim and also a curative orientation.

In contrast, the dominant treatment approach using stimulants (e.g. Ritalin) has a purely symptomatic effect; furthermore, around one-fourth of all children considered to be affected do not respond to stimulants or respond only negatively to them. Even if it is not always possible to avoid the use of stimulants during the 2nd seven-year period, the authors strive to find a path without stimulant therapy that aims towards at least partial healing/rehabilitation_i.e. a path towards progressive healing in the child's development.

Stimulants cannot accomplish this. The claim is presently made that stimulant therapy is a kind of substitution therapy for the metabolism of the central nervous system. When it is contrasted with true substitution such as insulin treatment for diabetes, however, this claim is found to be a largely hypothetical justification for the therapy. As a general rule, any substitution of substances can have problematic effects on the equilibrium and ultimately weaken the autonomous development of the child's metabolism. This in turn leads to continual medical checkups, with doctors warning their patients always to take their pills if they wish to avoid a relapse. In adolescence at the latest, this frequently leads to massive self-doubts and mis-use of the substances to be taken.

The question is, do not stimulants rather deserve the status of an acute treatment_a last resort when a child remains unresponsive, socially isolated or unmanageable despite every measure attempted? To closer observation it will also be evident that stimulants do exercise a suppressive action on many children—particularly in the soul realm, the realm where originality and creativity reside. As long as the therapeutic aim is healing and not management of a disorder, the use of stimulant therapy on attentionally disturbed and hyperactive children will represents a sometimes necessary but ultimately unsatisfactory solution.

2.1. General therapeutic considerationsThe first therapeutically significant step is to create a detailed clarification of the medical diagnosis that manifests an understanding of the child and his or her strengths and weaknesses. This creates new interest in the child as a human being_as an individuality that is only in the process of appearing and still has surprises in store for us. The aim here is to achieve a shared sense of how the child experiences important life situations and reference persons, and what (s)he is able and not (yet) able to do.

The second step consists in pedagogical counseling of the parents and_in an appropriate way_of the teachers and caregivers (cf. the idea of the protective circle). On this point there is excellent literature today; among many others we refer again to Henning Köhler (23, 23) and the work of Schmidt et al. (25). For practical purposes the reference guides of Neuhaus (16, 26) and Aust/Hammer (15) are quite helpful. As widely as their concepts may diverge, in dealing with the children one finds importance points of agreement.

Regarding the media question, the studies of R. Patzlaff (27) are fundamental; numerous literature references are also provided in the general parents’ guide by Goebel/Glöckler (28). It is important to establish authentic conditions for pedagogical progress by_for example_drawing awareness to parental relationship crises, economic pressures, etc. and working these through separately so that they are not played out through the child. In every form of attentional deficit, individually suited dietary counseling also plays a significant role.

The third step consists in evaluating if the kindergarden, school or nursery group is meeting the child’s needs. Frequently changes are advisable in group size, options for individual help, academic achievement standards, as well as in the amount of time the child spends in the institution. For example, an all-day school with qualified afternoon care may provide the family with critical relief. Finally, the authors have repeatedly seen children (age 10 and up) with massive hyperkinetic disorders and very difficult family situations make excellent progress without any stimulant therapy by spending several years at a curative-education boarding school based on Waldorf pedagogy. In any case, the children themselves say very soon if they are really profiting from the change and when this is the case they are willing to accept many unpleasant aspects of the experience. It is important for the advising physicians to acquaint themselves with the various schools and institutions in their area. Once these initial steps have been taken, the therapeutic approach in a narrower sense can be formulated. For this purpose we cannot understate the value of

• anthroposophical and homeopathic remedies.

Their action is not substitutive or suppressive like that of stimulants. Rather, when correctly selected for the individual, they stimulate organismic learning processes. They address the regulation of vital processes, the body of life forces that works in bodily growth and organic functions_as well as in memory function_while these are maturing. The engagement of the soul element in bodily functions is facilitated in this way. These remedies act not in an isolated way on the nervous system, but integrally on the organism as a whole. This is important because it is precisely the relationship of the nerve-sense system to the rest of the organism that is impaired in ADHD (cf. Pohl 29, Schmidt et al. 25). As a rule the length of administration depends on how long the child needs before (s)he has accomplished the step in learning and maturation that the remedy has stimulated and is able to stabilize it alone. Composite remedies with broad indications may require longer periods of administration (several months), while single potentized remedies will be given for weeks, months or as a single dose, depending on their efficacy and potency. The most remarkable publication on classical homeopathic therapy in ADHD is a compendium of cases from Reichenberg-Ullmann (30); for anthroposophical drug therapy one might point to von Zabern (31, 32) and to the general survey by Schmidt et al. (7).

In the authors’ experience, without a differentiated application of anthroposophical and homeopathic drug therapy it will appear necessary to resort to stimulants. Since there are few up-to-date survey works based on personal therapeutic experience here, we shall concentrate on this form of therapy.

• Non-medicinal therapies for ADHD must be approached in a differentiated way. The following forms of therapy have the advantage that the children acquire new capacities, or physical obstacles are eliminated (craniosacral therapy and rhythmic massage). These are steps towards real healing:

For the reasons discussed, these forms of therapy are also preferable to stimulant therapy, which takes a clear third place among therapeutic approaches. At the same time an ongoing stimulant therapy should not be simply discontinued. In such cases it should initially be complemented with the therapy forms mentioned above and later reduced or discontinued to the extent possible. Depending on the child’s age, it is important for him or her to be included in evaluating the therapy from the start. Many school children are capable of judging the efficacy of their treatment very well themselves.

Constitutional Dominance of the Metabolic-Limb System Manifesting as a Hyperkinetic Disorder (ADHD)

The Constitutional AspectConstitutionally hyperactive, impulsive behavior with attentional impairment (ADHD) shows a marked relation to the male sex, although in rare cases it also occurs in girls. It is not unusual for the family anamnesis to reveal disturbed development in earlier generations (father, male ancestors). Boys are characterized by a relative dominance of the limb forces over the centralizing head forces (which mediate inner calm and concentration); in these predisposed cases, the dominance appears particularly marked. This type of constitution favors a “short-circuiting” between environmental stimuli and limb activity along with deficient control (and guidance) of limb movement emanating from the head (disturbed motor coordination is striking in many of these children).

From the embryological viewpoint it is noteworthy that the regulatory connection between the nervous system and the musculature does not emanate hierarchically from the nervous system, but rather arises as structures of the central nervous system and the muscle blastemes are “brought into agreement” by the organism (i.e. by an unspecified center!) (33). When the central nervous system is recognized for what it is: a reflective organ necessary to the steering of body movement; and when the limb system is recognized for what it is: an independent system (34) which together with digestive and metabolic processes comprises the primary organ of the human will_then and only then does the mediating task become clear which the human being must accomplish during development. It is in the area of body and limb development that the female and male sexes differ most markedly. An explanation based on brain metabolism (the dopamine hypothesis), on the other hand, casts no light on the sex-specific character of ADHD.

Interestingly, the primary effect of the nerve on the muscle cell is that of inhibition (embryonically, fibrillation of the muscle cell interrupted for the first time when the growing nerve fiber reaches and penetrates it), while the original “modus” of every muscle cell is movement. In reality, the success of the mediating task mentioned above is not a process of the nervous system at all, but depends on the rhythmic system that mediates between the nerve and limb systems and on associated “soul” processes (respiration, circulation, spinal function and craniosacral rhythm – cf. (35). Movement and consciousness must be “brought into congruence” out of one’s own forces_that is the task.

As a rule, abnormal behavior on the part children with hyperkinetic syndrome becomes especially pronounced when they are in socially challenging situations. This too is connected with insufficient development of the rhythmic system, resulting in insufficient connection and interpenetration of the head and limb forces: The rhythmic system, which provides for a “breathing, resonating” kind of understanding, becomes “fragmented” by limb forces and impulses that take on a life of their own. The other children in a group as well as their parents are soon aware of this and need to feel that their situation is understood by the doctor in detailed consultations. The hyperactive children themselves also suffer, however, feeling overwhelmed by their own limbs and their spontaneous actions.

In the metabolic area (just as in children with food intolerances), one should be especially watchful for a labile blood sugar curve. Otto Wolff (36) points to the fundamental importance of the carbohydrate metabolism in hyperkinetic children. Many of them display a marked lability of the blood sugar level, which can lead to corresponding hunger phases (primarily in the a.m.) with increased sugar consumption and correspondingly greater, reactive blood sugar vacillations. Diet and medication can be effective here.

• It must be borne in mind that by its very nature, will-life proceeds without memory, comparison or plan; it moves from the now towards the future. In order for this to occur, the past must be forgotten. In a child who is carried away by his will, this means that the function of conscience can be suppressed and things of value from the past can be destroyed without any feelings of regret or guilt. Even an ability to lie without a bad conscience stems from the unbalanced dominance of the will-life. At any moment, however, this state can switch to feelings of regret or guilt once the “intoxication of movement” has passed.

A crucial factor in hyperactivity is the child's relationship to the father: Is he present? Is he active in their lives? As a man, by constitution his role lies in the use of his limb forces; the more harmoniously he does this and models it, the more positive the effect on the child. It is very important to bring the father into the child's upbringing in an appropriate way.

Ergotherapy, artistic therapies, curative education, school-preparatory work in small groups should always be considered and—most importantly—implemented at the right moment. How deeply they can change the constitution depends on the time of their use. The aim is to enable the rhythmic system to mature in the second seven-year period, and in hyperkinetic children the ground must be prepared for this (particularly at pre-school age). An especially significant aid to children with constitutional ADHD is offered by therapeutic eurythmy (see below), which can be received quite positively when it is carried out correctly.

Concentration and perseverance is best learnt by these children through meaningful physical activity (they can become very skilled and engaged in this area, e.g. in handicrafts). Constitutional remedies can have a decisive effect on the symptoms. A selection of important remedies is presented below.

Overview of therapy options with anthroposophical and homeopathic remedies

If the diagnostic process does not directly point towards a single remedy, it is advisable to begin treatment with a broadly acting anthroposophical composite remedy. In cases of constitutional hyperkinetic disorder (ADHD), a remedy suitable for basic treatment is:

Aurum/Stibium/Hyoscyamus comp. Glob. WALA5 – 10 globuli 2 – 3 x day,

especially for children who are• hyperactive/driven, and at the same time• aggressive and• prone to rivalries and physical confrontations.

This is among the "early composite remedies developed on an anthroposophical basis by the physicians' circle around Ita Wegman, MD, at the Klinisch-Therapeutisches Institut” (in the present form since 1935); the aim was to create a remedy that stimulates the rhythmic system to overcome "one-sided tendencies" in both the nerve-sense system and the metabolic-limb system (37). To this end gold, antimony and extracts of Hyoscyamus (henbane) are potentized together to create a new whole. The gold component (equivalent to D10 in the final remedy) addresses the heart and circulatory system, strengthens wakeful day-consciousness and—as abundant experience has shown—is particularly effective in cases where the child has too little exposure to the father. Antimony (D8) helps give structure to metabolic processes (e.g. promoting blood-clotting) as well as to mental life (psychiatrically valuable when the mind is flooded with an uncontrollable mass of chaotic contents). Hyoscyamus, in the potency used here (equivalent to a D5), impedes compulsive impulses from passing directly into movement and promotes the development of the rhythmic system (cf. the toxicity of this solanacean alongside of its rhythmically structured form). The action of this remedy includes a mildly antidepressive component that is helpful to many of these children.

Use of this introductory therapy stimulates the rhythmic system, and many children and families report feeling an unmistakable beneficent effect from it; at the same time it gives the physician time to get to know child and parents better and carry out the next therapeutic steps and conversations.

In the authors' experience, the following single remedies are the primary ones suitable for further individualizing the treatment. The potencies indicated are those commonly used; in individual cases, when the remedy is a good match but its action is insufficient, a higher (or lower) potency may lead to success:

It is telling that sulphur in mineral form is completely combustible and in its elemental form is involved in numerous metabolic processes. Sulphur, which is released chiefly by volcanoes from whence it enters the biosphere, always has to do with life and movement in nature. Potentized sulphur has a fundamental regulating action when the metabolic-limb system and the will-life associated with it gain too much independence from the soul life. Characteristics of children who benefit from this remedy are:• a remedy for boys• body build tends to be slender; pronounced postural weakness• intelligent but lazy. Seeks out disputes, likes to argue. Absorbs much in school despite chatting and appearing uninterested. • socially awkward, makes hurtful remarks, puts off others with arbitrary self-centered behavior; at the same time naive and gullible (these children are not really hard to understand)• handwriting nearly illegible, notebook disorderly, e.g. may be spotted with fat; child cannot (and will not) keep order; possessions are quickly broken (= high material "turnover rate”!)• typically display intolerable behavior when hungry, improving immediately on eating; craving for sweet foods (markedly improved by remedies); tendency to hypoglycemic phases in the 2nd seven-year period with behavior problems markedly increasing in late morning (around 11a.m.).

Medical history may show multiple allergies and descending respiratory infections (frequently treated with antibiotics); hence attention should be given to possible disturbance of intestinal flora (candidiasis). Eating a sufficiently sturdy breakfast—ideally based on oak flakes—is beneficial (and not only for this type of constitution).

Magnesite D6 – 12 Trit. WELEDA1 pea-sized portion 3 x or 1 – 2 x day

is an important and potent constitutional remedy particularly at kindergarden and pre-school age. Like sulphur, it addresses primarily the life-organization—the child's etheric body. Magnesite too is most suitable for boys. These children "stick out" because of their willful behavior and their physical and emotional assimilation problems. One gets the impression of a stunted etheric organization with poorly developed coherence. Let it be recalled here that magnesium in living organisms plays a crucial role in the absorption of sunlight (chlorophyll), making it a central element in the development of an independent etheric organization and the capacity for growth and assimilation. Leading symptoms for the application of this remedy are:• children are short-statured and thin, especially in the first year of life• will not eat before 9 – 10 o'clock in the morning• in most cases do not like vegetables (greens!)• bristly, contrary, irritable, oversensitive• seek argument• tendency to abdominal colics and acidic-smelling diarrhea• frequently restless sleep• in many cases such children suffer from family discord themselves.

is a remedy indicated for both sexes. Here the hyperactivity takes the form of a chronic (frustrated) dissatisfaction. Calc. phos. is synthesized out of two polar components, calcium and phosphorus, corresponding to the condition of continuous conflict found of these patients between the nervous system and the metabolic-limb system. Notable traits are:• continual dissatisfaction. The children constantly compare themselves with others and are very worried that they will be negatively judged (chiefly in regard to intelligence and looks). They themselves are very critical of others and express it. They want to be good—perhaps even the best— but generally are not. Bursts of rage result from this inner dissatisfaction and are manifested around learning difficulties. They are not very creative themselves and thus are dependent on others, yet they do not behave in a way that generates much sympathy. • the soul life with its catabolic action does not unite in a positive way with the metabolic-limb system, resulting in: tendency to belly aches and growing pains; poor and fluctuating appetite; inability to fall asleep until late at night; additionally in the 2nd seven-year period, a tendency to headaches triggered by physical and mental exertion.• tendency to disorders in region of the cervical spine as well as development of idiopathic scoliosis (girls)—also an expression of poor integration of the upper and lower person in the rhythmic region. In older children, the motor unrest can find an outlet in prolonged athletic activities; quite often with this constitution, impairments of the growth plates are observed (Apatite D6 is beneficial here.).• during puberty initial signs of restrictive anorexia may appear.

Painting therapy can be very helpful for children with this constitution in the 2nd seven-year period.

Carcinosinum C30, 200 Glob (var. manufacturers), single doses

is an important remedy in differential therapy with calcium phosphoricum; one should not fail to consider its use. Here too we see a primary weakness of the rhythmic system. The children in question are fundamentally ambitious in the aims they set themselves (which are often unconsciously adopted from others), but lacks the energy to achieve them. Feeling disappointed by the world around them, they continually drive themselves into a corner. Striking symptoms are:• profound restlessness and poor concentration, coupled with• a mood of pronounced frustration and lack of motivation which cannot be dispelled• they work hard without satisfactory results until they reach the point where they stop doing anything for school.• they have great difficulty undertaking anything on their own initiative and need a social context in order to become active. They attach great importance to acceptance by their peer group and like to travel.This remedy is also indicated for both sexes.

Belladonna Rh D20 Dil WELEDA 5 drops 1 x day

is among the remedies (along with Hyoscyamus and Stramonium) whose indications include aggressive behavioral disorders. In relation to ADHD, the ADADHThe following characteristics are typical:• early awakening of consciousness; children who listen to the doctor in conversation; one can speak with them: intelligent children!• they become aware of their tendency to uncontrolled behavior at an early age without being able to control it• they tend to have acute attacks of rage (similarly, they suddenly develop high fevers during acute infections) with biting (chiefly in young children), hitting as well as autoaggressive behavior. Many of their illnesses occur in attacks, with pain occurring as acute colic pains• they hate being touched—especially on the head—and any kind of wrapping or constriction• they develop fears—fear of thunderstorms, dogs (a fear of being attacked the way they might attack others!), water and the dark.

As much as these children reject touch, diapers and tenderness in the daytime, two hours after falling asleep they may run to their parents' bed in a sweat: When the life-organization expands upwards in sleep and the soul releases its hold, the child enters a crisis of neediness. The soul of these children does not unite harmoniously with their own body and surroundings, instead appearing suddenly and overpoweringly like a demon ready to pounce (cf. the toxic process of the deadly nightshade): The children are carried away by it without being able to guide the process. In these cases Belladonna is a very important constitutional remedy—it is a mistake to reserve Belladonna for acute illnesses only.

Stramonium D12 Glob. (var. manufacturers), 5 glob. 1 – 2 x daily.

The doctor’s first meeting with the child provides a characteristic indication for this remedy:• child generally displays adapted behavior in the consultation room, but avoids eye contact or a direct meeting; shies away out of apparent uncertainty and anxiety; may stutter; acute illnesses may take an intense course leading to spasms of the respiratory tract.• in the home, anxiety is also noticed by the parents at bedtime (especially the need for light when falling asleep, fear of being alone) • this is paired with sudden, unmediated aggressivity that may be quite intense (as with Belladonna), but the child is less aware of it—the adapted side knows nothing of the uncontrolled, aggressive side, resulting in a Dr. Jekill-and- Mr.-Hyde type of split: the nerve-sense and metabolic-limb systems become dissociated • attention is more obviously impaired than in Belladonna

In this difficult situation, Stramonium is a potent remedy that is effective in complementary therapy of ADHD. Regarding the use of Hyoscyamus in ADHD, the authors use it essentially as a component of the composite remedy Aurum/Stibium/ Hyoscyamus described above; as a single remedy (Rh D6 Dil WELEDA) it is important in treating forms of epilepsy associated with ADHD-type symptoms.

is another important single remedy (a native poisonous plant). Interestingly, its blossom blends from dirty white into the green of the foliage with unusually little differentiation (the blossoms are relatively inconspicuous), while the root—well-developed for a plant of the lily family—is permeated with a powerful toxic process that causes metabolic collapse in the human being. These patients (cf. the hypotonic, vegetatively labile type) seem to be insecurely anchored in their own body, circulatory system and metabolism and attempting to compensate for this by constant motor unrest. The gesture of these children is one of boundless overflowing sympathy, manifested in• wanting to grasp, touch, hug and kiss everything• feeling very nervous and inwardly driven • show a pronounced liking for sour food (which stimulates astral activity in the digestion)• strong motoricity alongside of tendency to cool extremities and quickly developing peripheral cyanosis• at the same time they show a liking for cold foods ("The symptom cold is characteristic of all effects of Veratrum," says J. T. Kent in his introduction)• intense abdominal colics, vomiting, diarrhea and (in girls) dysmenorrhea always associated with circulatory weakness and coldness all show that the soul organization—the astral body—does not "feel at home" in this area and cannot integrate positively with the metabolic-limb organization

External applications for these children should focus especially on the kidneys. We recommend application of

is indicated in cases of primary metabolic weakness: These children are generally frail, develop slowly, quickly feel sated at meals, do not like to chew and crave sweet foods; breaking-down processes in the upper abdomen are deficient, resulting in a tendency to bloating and constipation as well as a high frequency of allergies. The chief liability here on the attention is chronic stuffy nose, which—like the digestive condition—can be improved medicinally. This remedy is helpful for • boys• who are clingy to their mothers but need validation from their peers;• are afraid when alone and may sleep with a sibling to avoid being alone;• prefer to hide their weaknesses,• yet are ambitious, expecting a great deal of themselves or having the feeling that others do.

The hyperactivity is moderate, taking the rather subliminal form of nervous unrest with attentional weakness due to metabolic weakness and inner nervous tension. It is important to air the issue of parental expectations and to include the father in this discussion. Supportive measures for these children are yarrow compresses on the liver, adequate fluid intake and use of Hepatodoron Tbl. WELEDA for regulation.

Potentized mercury is helpful mainly when:• children are “inaccessible” to the doctor,• they get out of every rule, "slipping through" everywhere,• they have a tendency to purulent inflammations,• hyperactivity is pronounced.

One may have the impression that the rhythmic system is becoming independent of the calming/guiding function of the nerve-sense system (cf. Steiner's description in the Curative Eurythmy course (38). When difficulty falling asleep is also an issue, this points to

is indicated when the nerve-sense system does not exert a calming and guiding action in the organism but produces instead an undirected catabolic tension. This will be manifested in that the child• constantly feels driven and restless;• loves movement in the fresh air, external cooling• suffers from nervous anticipation• tries to compensate with sugar consumption, which only further aggravates the nervousness (variable blood sugar level)

This homeopathic remedy is derived from a poisonous spider, the Spanish tarantula, and exerts an exciting action on the rhythmic system. It is suitable for girls and boys with pronounced constitutional ADHD: They appear constitutionally strong and have inexhaustible energy which enables them to blithely ignore all inner and outer obstacles, as immediately becomes clear at the doctor's office:

• they like to dance and climb• they can behave deviously and even deceitfully, stealing and breaking things • they are constantly asking for attention• reprimands are manifestly pointless and make no impression on these children• a point to note: they may be subject to fear of spiders and insects• in the respiratory realm one sometimes notes the development of stuttering and asthma

An indispensable remedy in the treatment of hyperactive children is the homeopathic nosode

Physically one very often notes a chronic susceptibility of the respiratory passages, particularly in the middle ear and lungs; behaviorally one is struck by a

• cold-blooded destructiveness: No object of value is safe from these children; without qualms they will smash a beautiful vase before the eyes of its owner, or a friend's toys—or, just as soon, one of their own favorite possessions!• punishments have no effect at all• they are highly intelligent and in many cases artistically disposed• they are unable to remain in one place for long and love to travel

Compared with Tarantula hispanica children, these children appear to act in a more skillful, controlled and considered manner. They are capable of deceiving adults, while the tarantula types typically follow their own impulses thoughtlessly.

In conclusion, we shall mention two more remedies for ADHD which are indicated when the symptoms appear in combination with other disorders—primarily those of the nervous system.

The fly agaric mushroom has been used in many parts of the world as an intoxicant. The symptoms it evokes are similar to those of ADHD. As a potentized remedy, Agaricus should be considered particularly for:• tics associated with ADHD or resulting from treatment with stimulants• risky, impulsive and erratic but essentially well-intentioned behavior• these children wish to be helpful and good• in fits of rage they can display tremendous strength

The anamnesis may reveal prior injury to nervous system (in this case Steiner attributed great therapeutic significance to Agaricus); clinically as well, these children give the impression of having a neurological inhibition deficit.

Potentized zinc is of chief therapeutic value in cases where the formation of the nervous system has been impaired through such factors as extremely premature birth or a convulsive disorders, and competency deficits are prominently in evidence. The symptoms of these children are:• very easily distracted, fidgety and restless• memory is weak and judgment uncertain• over-excited states alternate with stuporous inactivity• make frequent slips speaking and writing• subject to the familiar „restless legs” syndrome (Zincum valerianicum is indicated here as well), especially in bed before sleep.

Potentized phosphorus is not used by the authors for children with manifest hyperactivity, as this remedy very often has an aggravating action in ADD + H. The situation is different in dominant attention deficit without hyperactivity (see below).

Therapeutic EurythmyHyperactive children demonstrate an obvious liking for therapeutic eurythmy exercises and often experience them as beneficial. Waldorf Schools provide the opportunity for therapeutic eurythmy to take place during the school day. The proven approach is to conduct it in the mid-afternoon—at first every day if possible, later less frequently. Before commencement of therapy it is vital that the physician and therapist reach a thorough common understanding. The therapist herself should radiate confidence, joy in movement and a certain willingness to experiment.

Hyperactive children often appear unprotected, exposed defenselessly to their environment and its influences without any ability to come to peace or feel at home within themselves. As an introductory exercise, the rhythmic system can be stimulated by expansion and contraction. Basic vowel exercises with U (oo) and A (ah) then follow: First one can take the U upwards “to the stars” and then down to about heart-level. Then one can make the transition to the A, letting it radiate out as it rises upwards: The inner sensation is one of growing brighter; the A promotes the connection of the soul with the body—the internalization of the soul-spiritual individuality.

The first therapeutic eurythmy exercise ever indicated by Steiner was for children who became “more and more fidgety” until their teacher was at a loss what to do (39). For this he recommends a specially executed A-exercise, the “fidget iambus” (39). Among consonant exercises, the B provides a sheath and a boundary, control of nervousness and motor unrest. It can be helpful for the patient to picture a coat of “blue armor” around himself during the exercise. The B can be intensified by the P-gesture; a further complement—especially important with aggressive, hurtful behavior—is the S. A sound sequence appropriate for children with clearly hyperkinetic behavior is: MNBPAU, known as the “calming sequence.”

Another important and proven benefit comes from offering therapeutic eurythmy to the parents as well. Parents find it a great relief when they no longer get upset at their children, where formerly they might turn into a copy of their “little dictator.” Appropriate exercises for this purpose are “Steadfast I stand in existence” and “I think speech.” Like the others, these exercises must be learned with the help of a trained eurythmy therapist and practiced every day. Only a few minutes are needed, however, and the effects will be directly experienced and will radiate out into the life of the family.

2.3. Attention and Concentration Disorders without Hyperactivity (ADD) (Competency and Learning Disorders)Definition and Basic TherapyToday this concept embraces early childhood brain function disorders, specific learning disorders and attention deficit disorders in the narrow sense; the concept of ADD without hyperactivity is “problematic” as to its scientific validity (cf. (40)). Diagnostically the concept is inadequate and needs to be made concrete in individual cases. Differing figures are given for the ratio of boys to girls, while in practice the sexes are equally affected—in complete contrast to hyperkinetic syndrome. The underlying reasons for attentional and concentrational weakness may be:

as well as the aspects mentioned initially as having significance in differential diagnosis. Another important element is that the unusual behavior is continual and does arise reactively. At the same time excessive academic demand can become manifest in a relatively acute way—e.g., after a school change. Premature children born before the 32nd week of pregnancy often present a spotty nerve-sense competency picture that defies easy classification; they frequently have difficulties integrating and processing their perceptions, while quite often there is also a short attention span with a metabolic background.

The following section presents in detail the possibilities for treatment with anthroposophical and homeopathic remedies—many of them not well-known. In addition we refer the reader to the literature cited at the end.

A good basic therapy for children suffering from disorders of attention and concentration is the anthroposophical composite remedy developed by K. Magerstädt:

Potassium phosphate has an action relating to the liver/gall bladder system; it opens the metabolism in the morning to the catabolic processes (linked with phosphates) that are necessary for consciousness—for processes of “inner light formation.”

This remedy is indicated for all children who:• display “lack of energy” for attention and mental processes and quickly become exhausted by mental activity (and “turn off”)• fail to become adequately awake in the morning• appear exhausted when they are first seen by the doctor due to the long history of their troubles• develop mental blocks and headaches from extended mental exertion

Like Aurum/Stibium/Hyoscyamus, this remedy contains Aurum met. praep. D10 and thus has a mild antidepressive and energizing action (cf. above). It also contains a low-potency iron-sulphur-quartz preparation (corresponding to the WELEDA’s Kephalodoron) which stimulates incorporation of iron into the digestion and metabolism and thus indirectly has an energizing action. The remedy has a broad and reliable action and is ideal as the initial remedy of a treatment.

For a certain number of these children, an effective complement will be found in the organ preparation

This chiefly stimulates renal function and the day phase of the liver metabolism (cf. also children with vegetative lability and hypotonic circulation) and is also suitable as an initial treatment. Finally, extracts of rose blossoms,

Rose Elixir WALA 1 tsp. 3 x daily right before meals

provides highly effective support for which is expressly appreciated by many children with attention and concentration disorders. It is suitable even for small children—cases of extreme prematurity, for example—and has a positive action with:

The blossom of the cultivated rose, whose color, fragrance and harmonious form affect the soul so positively, is the product of human cultivation. In this process, vegetative vitality has been transformed into a substance that is devoted wholly to “ensouled” nature and has meaning only in this context.

A similar process must be performed by the human organism in order to make thought processes possible—it is no accident that north of the Alps, rose cultivation was first practiced in the monasteries. The indication for administering Rose Elixir is to promote calm concentration on a thought.

One general therapeutic option for children with simple ADD without hyperactivity is offered by low potencies of Coffea, a plant which itself synthesizes a substance with a stimulating action: caffeine.

can markedly improve attention and concentration in these children while avoiding the undesirable effects of substantial stimulants. Here again, the underlying principle of action is that of stimulation, not of substantial substitution.

When the background of the ADD symptoms lies in disorders of the nervous system (e.g. sequelae of cerebral hemorrhage, early childhood epilepsy, etc.) with competency deficits, Arnica can be of comprehensive benefit to the nervous system, particularly in the form of an oil-dispersion bath (developed by Junge; information provided by WALA as the manufacturer of the oils):

Arnica e flor. W 5% Oleum WALA, 3 – 5 ml/full bath

Internal remedies for this indication, with a view towards stimulating maturation of the nervous system, are:

is the most important homeopathic single remedy for ADD. Interestingly, the winter-blooming Christmas Rose forms high concentrations of Beta-Ecdysone, a substance that is important as an inducer of metamorphosis in animate organisms (in hormonally active fine concentrations)—e.g. the metamorphosis from caterpillar to butterfly. Its possible function in the maturation of the nervous system is being explored (personal communication from Dr. Schlodder, of the company Helixor). Helleborus niger is indicated when the nervous system fails to develop adequately as the instrument of consciousness (a disorder of organ development and metamorphosis):

• the children appear absent, "spaced out"• sensory impressions are insufficiently processed (disorders of central perception processing)• intelligence may be impaired, possibly as a result of inflammatory and traumatic pathologies of the CNS• no hyperactivity is present, but symptoms are aggravated from anticipation anxiety (e.g. exam anxiety)• memory is weak; the children have trouble committing things to memory

Contrasting with this picture, there is the type of the intellectually bright child who tends to be delicate and mobile by constitution, sanguine by temperament and empathetic by nature. These generally artistically gifted children have a basic tendency towards distractibility. Their attention and concentration problems set in primarily during the light-deprived season, at which time they are also more susceptible to infections, particularly of the respiratory passages. In this case,

Phosphor LM6 Dil Arcana in the morning,beginning with 1 – 2 drops daily and increasing to 5 drops daily if no unrest sets in

offers an effective constitutional remedy: Phosphorus enables these children to be mentally present and their susceptibility to infection decreases markedly. This treatment can be complemented with evening embrocations of the back or oil-dispersion baths with Hypericum oil during the light-deprived season.

Chiefly among girls, one observes a type of temperamentally phlegmatic child who seems to go into “hibernation” during the cold season. Such children are also prone to seasonally aggravated attention and concentration impairment related to light deprivation. Regardless of season, they would most prefer to sit in front of the television and eat. They like to move about in the water, which gives them buoyancy (they love trips to the swimming pool). Overall their development is steady although it may be slow. Under present-day schooling conditions these children may stand out primarily because they:

• seem absent and dreamy• forget homework and fail to properly note assignments• appear heavy and sluggish in their movement• take a long time with every task and have great difficulty getting started

In the warm season they are much more active, get more exercise outside and also develop more mental activity and flexibility. In many cases one of the parents recalls having once had similar traits themselves, or may still manifest a certain sluggishness and phlegmatic temperament. Even so, the continuity of their development_their health_is always clearly recognizable; their problem of one of adaptation to their environment and to specific seasonal conditions. An effective remedy in these cases is

Calcium carbonicum LM6 Dil. Arcana,5 drops 2 – 3 x day

Possible complements to this treatment are phytotherapeutic doses of St. John’s Wort extracts, e.g.

Hyperforate, 10 – 15 drops 2 x daily

and insistence on sufficient outdoor physical activity_while the sun is shining_even in the cold season.

If weakness of memory in an ADD child stems from lack of interest_unwillingness to pay adequate attention and poor memory in spite of ability_then

Cuprum sulfuricum D6 Dil. WELEDA 5 drops 3 x daily

can put the child in a receptive and at the same time relaxed state.

Children who are markedly • strong-willed, but at the same time• mentally lazy

can be stimulated towards greater attention and mental order by administering

is indicated for children who manifest weakness of the I-organization: They appear slightly sad and depressed and have great difficulty starting a task_they can’t ”get going” or “muster the will” to begin.

is indicated for children who are quickly exhausted mentally:• headaches and thirst after school are a leading symptom of this constitution. These children are also prone to allergic rhinitis_in some cases perennial_which in turn further impairs their attention and concentration.

Children who• manifest difficulties with arithmetic and logical thought but have no other difficulties_e.g. with reading and writing_ benefit from treatment with potentized natural calcium phosphate (apatite) and tin:

Apatite D12 Trit. WELEDA1 knife-tip in the morningandStannum met. praep. D12 Trit. WELEDA1 knife-tip in the eveningas well as Stannum met. 0.4 % ointment WELEDAapply a pea-sized amount to forehead in the morning

A deep-acting metallic remedy to stimulate differentiated thought processes is silver antimonide (dyscrasite). The essential action of potentized antimony is to promote structuring processes in the organism, while silver in high potency has the power to stimulate the vitality of the nervous system.

Dyscrasite D30 Dil. WELEDA, 5 drops in the evening, is indicated for children who

• have an attention deficit and mental weakness• tend to be clumsy and undifferentiated in fine motor behavior

These children also benefit greatly from learning to play a musical instrument, e.g. the flute, which also supports mental development (important in the second seven-year period).

In contrast, lead in the form of

Plumbum met. praep. D10 Trit. WELEDA1 knife-tip in the morning

is indicated for children who are

• large-headed, with hints of hydrocephalus, and at the same time physically slender• markedly retarded in mental development• late with toilet training in many cases and slow to catch up developmentally

Children with Disorders of the CraniocervicalTransition

Pathogenetic ConnectionsFrom osteopathy and craniosacral therapy we know that the transition from the posterior skull base to the cervical spine in the human being is very sensitive and susceptible to impairment (41). As background to this issue, it must be recalled that the entire connection of the osseous skull and the vertebral column—derived from the chorda dorsalis—is an oscillating system of more or less mobile osseous structures. In the region of the craniocervical transition, the capacity for oscillation and rhythm is subjected to great stress in neonates and infants (particularly by the birth process), frequently resulting in pathological deformation due to vertebral body displacement, impairment of normal mobility of the vertebral joints, as well as congenital disorders (42). Scientific studies confirm today that this region is particularly susceptible to impairment in the first six months of life_in certain cases it may also be linked to Sudden Infant Death Syndrome (SIDS), the incidence of which increases four-fold in children who sleep on their stomach, i.e. with heads sharply turned (43). Blood supply to the brain is dependent to a considerable extent on the vertebral arteries, and these can be significantly irritated by impaired balance, vertebral body displacements, as well as impaired mobility in the cervical spine/skull base area.

From the embryological point of view, B. Christ (44) speaks of the region of “the cervicooccipital transition as a ‘vital center’ of the human being”: The earliest embryonal vessels can be detected here; regulation of breathing and circulation is localized in this region; and central formative processes of the rhythmic system have their origin here—among others, the septation and crossing of the outflow paths of the heart and development of the intramural nerve plexus of the gastro-intestinal tract, which enables peristalsis there. This underscores the importance of understanding the spine, and particularly the craniocervical transition, as a part of the rhythmic system: Disorders of the vertebral column, of circulation and possibly of respiratory regulation and motor activity act directly on one another here.

Clinically, the pathological picture in question shows restricted rotation, palpable asymmetries of the uppermost transverse processes of the cervical vertebral bodies and of the pulsations in the region of the cervical spine, as well as asymmetries of the shoulder girdle. A mixed picture may arise with painful tension of the cervical musculature alongside of relative muscular hypotonia in the vertebral sections beneath them. Disorders may also affect tonus of the mimic musculature of the face and jaw position. Ex juvantibus, the diagnosis is confirmed by the fact that after appropriate treatment of the cervical spine, the children’s behavior undergoes a marked improvement_in some cases practically overnight.

In such disorders we recognize a dissociation between head and body which requires further in-depth anthroposophical study. The result of this dissociation is that the forces emanating from the head pole, which are responsible for forming the body out of the soul-spiritual individuality of the child, are unable to exert their full efficacy and penetrate the limbs. The will forces that have their primary action in the limbs enter into a wrong relationship with the impulses from the head pole_they fail to engage properly in the child’s organism. In the first seven-year period, however, the constituting process of the organism is dependent on the metabolic-limb organization’s adapting itself to the head-mediated formative impulses from the child’s higher self.

Therapeutic Optionsare offered by practitioners of osteopathy or craniosacral therapy who have undergone further training in child neurology/orthopedics or have been trained in physical therapy on a neurophysiological basis as well as one of the therapeutic fields mentioned. Specific experience with children is indispensable. The space between treatments should be at least 1 – 2 weeks. Any positive effect should be recognizable within this time period.

This treatment can be supported and stabilized medicinally by administration of

For early diagnosis and therapy, craniosacral therapy and osteopathy have a significant role to play_primarily in ADHD, but also for any child with a problematic neonatological anamnesis: In case after case one is struck by the results of this treatment: Infants who formerly exhibited the classic early symptoms_inexplicably long crying phases, motor unrest, eating, sleep and mood disorders_become relaxed and calm and find their way into very much better day/night and eating rhythms as well as much more harmonious motor development.

2.5 Children with Vegetative Lability and Labile Hypotonic Circulation

What is striking to the doctor about this group of children is the instability of their rhythmic system:• fluctuating, situationally and positionally dependent disorders of warmth distribution with varying degrees of pallor• cool and sweaty extremities, perspiration of vegetative origin, dermographism• tendency to abdominal pain, indefinable and changing unpleasant sensations, later headaches (tension headache or migraine-like headaches)• in some cases a complaining, anxious state with little basic trust• nervosity

These frequently-encountered symptoms intensify markedly around the ninth year, during growth spurts and in the pubertarian separation phase, and then may lead to manifest attention disorders. Disorders of the craniocervical transition can aggravate these symptoms (see above). As a rule, impairment of attention and concentration is inconstant; among children prone to intense motor unrest, one can have the impression that they are creating constant motor stimulation in order to achieve adequate body tone (in cases of pronounced hyperkinetic symptoms, cf. above, e.g. Veratrum album).

A basic therapy suitable for these children is

Cardiodoron mite Dil. WELEDA. 5 – 15 drops 3 x daily.

Its stimulating action on the rhythmic system is comprehensive, so it should not be thought of simply as a “heart remedy”. This action gives it a broad and important indication particularly for the 2nd seven-year period, since this is the age when the human rhythmic system undergoes its most extensive development (lungs, heart/circulatory system, vertebral column). Roughly half of these children_primarily those with combined weakness of the heart/circulatory system and the digestion_show obvious benefit from simultaneous administration of the organ preparation

Glandulae suprarenales comp. Glob. WALA 5 – 10 glob. 3 x daily.

The most important metallic remedy for children of the type described here is potentized iron. If the symptoms match the above description without hyperactivity or if one is dealing chiefly with boys whose maturation in the 2nd seven-year period has been rather inhibited and who seem a bit “too soft,” then

Ferrum met. praep. D10 – 12 Trit. WELEDA1 knife-tip in the morning

is indicated. When the problems arise in the context of a growth spurt (the child grows too fast and mentally “nothing works anymore”), an extract of blackthorn blossoms and shoots processed and potentized together with iron oxide has proven most effective and beneficial:

Prunuseisen Glob. WALA, 7 – 10 glob. 3 x daily

When the child is in a weakened state due to prior illness or emotional issues, etc., or when there is a tendency to hypotonia and latent depressive states, then a remedy combining Prunuseisen with Levico water and Hypericum is more effective:

Levico comp. Glob. WALA, 5 – 10 glob. 2 – 3 x daily.

A broadly indicated remedy for hypotonic circulation, attention and concentration deficit is

Skorodit Kreislauf Glob. WALA, 10 glob. 2 – 3 x daily, primarily to be given in the morning and at noontime.

This composite remedy is based on scorodite (iron orthoarsenate) complemented by Veratrum album and Prunus spinosa. It is helpful primarily in puberty and adolescence, especially when a remedy is needed for quick tonifying and strengthening. These patients appear without energy, sluggish and hypotonic, but not off-putting or aggressive.

Cralonin Heel drops, 20 drops 2 x daily for school children

contains hawthorn extracts and thus has a harmonizing and stabilizing effect on blood circulation. It is effective in cases of orthostatic tendencies as well as anxiety and piercing chest pains without specific cause, which are not uncommon at this age.

In this section focusing on therapy for the rhythmic system, we must emphasize the overall importance of• clear guidance and rhythmic structuring of the child's day— particularly the morning and evening hours (cf. also section 7.1)• lots of outdoor exercise (in all weather) and purposeful movement (engaging the child in house and garden work, riding, etc.). Further suggestions are offered by Köhler (46).

2.6 Food intolerances

Over the last 20 years, Egger (47) has demonstrated convincingly in numerous publications that the behavior of a portion of hyperkinetic children can be significantly improved by means of an "oligoantigenic" diet. Hypersensitivity to specific Hyfoods—primarily sugar, coloring agents and preservatives and phosphate-rich foods—is different in each case.

Generally these are not classical cases of allergy but intolerances ("idiosyncrasies") which have remained unrecognized and cannot be detected until the chief incompatible foods are methodically excluded in the context of an elimination diet and subsequently re-introduced on a trial basis. Thus one can start with a basic diet that is known to be compatible and then step by step re-introduce previously eaten foods according to a set plan, thus recognizing incompatibilities. Sugar and food additives are often found to aggravate the symptoms. At the same time some patients have a craving for incompatible foods—an aspect that has been studied from an anthroposophical viewpoint by Otto Wolff (36); directly relevant indications can also be found in the works of Rudolf Steiner (48).

Anthroposophical understanding highlights the importance of spleen activity for complete assimilation of food in the human organism. Steiner's picture of the significance and pathology of this organ-activity is remarkably congruent with what is observed in hyperkinetic children with food intolerances and addiction to sweet or incompatible foods. This aspect also has therapeutic implications (see below).

In practical terms, one may proceed as follows with this group of patients: • ascertain the compatible diet by careful anamnesis, elimination diet and dietary counseling; this is time- consuming, but absolutely essential for each child. N.B.: The proof of a positive result is that it is experienced by parents, teachers and the child.• stool diagnosis (intestinal flora, pancreatic function), promotion of symbiosis and mycosis treatment (if necessary).• medicinal therapy addressing particularly: food breakdown; border surface function of the intestinal mucosa; liver and pancreas.

Sulphur LM6 Dil. Arcana, 5 drops in the morning

is indicated chiefly for vacillating blood sugar levels with the typical sudden sweet-craving and associated aggravation of behavior. It can often rapidly stabilize the blood sugar level.

with its potentized antimony, has a generally ordering effect on hyperkinetic children; similarly, the organ preparation Pancreas has a positive action not only on the digestion but also on blood sugar regulation.

Lycopodium comp. Glob. WALA, 5 – 7 glob. 3 x daily

is indicated particularly when toxic stress is a consideration.

Lien Gl D6 or Lien/Plumbum Amp. WALA

strengthens spleen function and the immune system associated with the intestinal mucosa (ontogenetically related to the spleen).

A midday nap with a warm liver compress (e.g. yarrow tea) also has a beneficial action on the entire digestive and metabolic function; it is supported by

Hepatodoron Tbl. WELEDA1 tbl. after both lunch and dinner

The Role of Stimulant Therapy

Stimulants (e.g. Ritalin) do not heal—this must be recalled again and again. Stimulants may be indicated in cases where in spite of all everything attempted the child remains unreachable and socially isolated or unmanageable: in acute situations aggravated by family, school or other circumstances. As a suppressive and perhaps substitutive treatment, stimulants represent a therapeutic principle which is completely comparable to steroid inhalation for bronchial asthma or longterm antibiotic therapy for cystic fibrosis. Stimulants are an expression of the power of modern scientific medicine: They put psychopharmaceutical drugs into the hands of the child/adolescent psychiatrist that are comparable with those of other medical specialties, thus increasing his or her status. This exerts a seductive power while also posing the danger of therapeutic resignation. The therapeutic goal particularly of pediatrics and anthroposophical medicine is healing: stimulation of the living capacity for self-regulation, strengthening the forces of the individual personality and patiently working through the child's limitations of body and soul.

The alternative to stimulant therapy is to make an intensive diagnostic and therapeutic effort for each single child. It requires a differentiated command of healing techniques and remedies, collaboration with the family based on mutual trust and adjustment of the home and school environment in accordance with the child's needs.

In severe cases of hyperactivity, a boarding school for curative education may make a critical difference during puberty. The path towards a pediatrics dedicated to the individual and to longterm healing requires the resolution to abstain, if at all possible, from stimulant therapy.